A Review of Infrastructure Support for Aboriginal and Torres Strait Islander Health

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Promoting the Health of

Indigenous Australians

A review of infrastructure support for Aboriginal and

Torres Strait Islander health advancement

Final Report and Recommendations

December 1996

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© Commonwealth of Australia 1997

ISBN 0642272298

This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source and no commercial usage or sale. Reproduction for purposes other than those indicated above, requires the written permission of the Australian Government Publishing Service, GPO Box 84,

Canberra ACT 2601.

The strategic intent of the NHMRC is to work with others for the health of all Australians, by promoting informed debate on ethics and policy, providing knowledge based advice, fostering a high quality and internationally recognised research base, and applying research rigour to health issues.

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Preface

Despite many new and welcome developments, Australia is yet to achieve a comprehensive national system for promoting the health of the population. The situation is all the more tentative when one considers the very real need for provision of specialised infrastructure to support the planning, delivery and evaluation of health promotion programs appropriate to Aboriginal people and Torres Strait Islander people. It was for this reason, and the strong desire of the National Health and Medical Research Council to consult directly and

appropriately with Aboriginal people and Torres Strait Island people themselves, that a separate review of infrastructure supports for Aboriginal and Torres Strait Islander health advancement was undertaken as part of the Health Australia Project. The Council is greatly indebted to Ms Sandra Angus, who was ably assisted by Ms Marilyn Wise and the Project Advisory Committee, for the production of this landmark and culturally attuned report.

The larger review of infrastructure support for national health advancement has essentially two goals:

• to identify steps to be taken to make Australia’s infrastructure for national health advancement among the best in the world; and

• to recommend actions to strengthen the capacity of Australia’s health sector to lead, enable, and support the development and delivery of effective interventions to promote, protect and sustain the health of all Australians.

A separate final report, with its recommendations, has realised these goals with respect to the more generic level of infrastructure development. This report complements and extends those findings through the identification of issues that are specifically relevant to Aboriginal and Torres Strait Islander health and by making targeted recommendations which reflect a broad consensus of Aboriginal views achieved through extensive consultation. The report provides an important and timely opportunity for all Australians to listen to what the Indigenous people of this country have to say about what is needed to advance their future health. C. D’Arcy J. Holman

Chair, NHMRC Health Advancement Standing Committee December 1996

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A review of infrastructure support for Aboriginal and Torres Strait

Islander health advancement

Project Team

Ms Sandra Angus Ms Marilyn Wise

Project Advisory Committee

Dr Wendy Brady Mr Chris Coomer Mr Brian Dixon Ms Anne Flood Ms Mavis Golds Mr Richard King Ms Maureen Kirk Ms Ester Rose Manson Ms Beryl Meiklejohn Ms Leanne Mick Mr Philip Mills Ms Deborah Reid Ms Trudi Sebasio Ms Juanita Sherwood Ms Denise Troon

Project Executive

Professor D’Arcy Holman Professor Don Nutbeam Ms Judith Dwyer Dr Tony Adams

NHMRC Health Advancement Standing Committee

Professor D’Arcy Holman (Chair) Professor Chris De1 Mar

A/Professor Rob Donovan Ms Judith Dwyer

Ms Sophie Dwyer Dr Colin Mathers A/Professor Terry Nolan Professor Don Nutbeam Professor Beverley Raphael Ms Rosalie Viney

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Contents

Preface

The Project Team

The review of infrastructure support for national health

advancement: terms of reference

Acknowledgements

Abbreviations used in this report

Executive Summary and Recommendations

i

i i

v

vii

ix

xi

Part 1:

The consultation with Aboriginal and Torres Strait Island

health personnel, organisations and communities

Part 2:

A brief review of the health of Aboriginal people and

Torres Strait Island people

2.1

Part 3:

Underlying causes of Aboriginal and Torres Strait Islander health status 4

3.1 3.2 3.3 3.4

Part 4:

Rhetoric or reality? Past and present policies act as

barriers to better health gains

Aboriginal policy

Infrastructure and funding for Aboriginal and Torres Strait Islander health The National Aboriginal Health Strategy

Other initiatives

Improving the health of individuals and of the population:

providing health services and promoting health

Part 5:

Infrastructure for promoting Aboriginal and

Torres Strait Islander health

5.1 Principles of good practice in promoting Indigenous health

5.2 Infrastructure for health promotion program delivery

5.3 In summary: limited infrastructure for health promotion

1

3

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11 12 15 15

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Part 6:

6.1 6.2 6.3 6.4

Findings from the consultations

Acknowledgement of the effect of their history on the health of Aboriginal people and Torres Strait Island people today

Extended health policy framework developed with strong Aboriginal and Torres Strait Islander participation

Effective systems at national, State/Territory and local levels to design and deliver health promotion programs

More transparent processes to identify priorities and allocate resources for promoting health

6.5 Organisational support for health promotion

6.6 Partnerships within the health sector and with other sectors 6.7 Research, evaluation and dissemination of good practice 6.8 Workforce development

Part 7:

Conclusion

Appendices

Appendix 1: Feedback on the first round of the consultation process Appendix 2: Participation versus consultation

Appendix 3: People who contributed

References

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25 25 2 6 2 6 27 28 3 0 31

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35 39 42

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The review of infrastructure support

for national health advancement

The National Health and Medical Research Council’s Health Advancement Standing Committee was commissioned to undertake a comprehensive review and analysis of past and current health promotion initiatives in Australia. The review was intended to inform the preparation of a report by the Committee detailing a range of actions to strengthen health promotion activity. A specific consultation with Aboriginal people and Torres Strait Island people was established as a major component of the review. This Report addresses the issues from the perspective of (and in the words of) Aboriginal people and Torres Strait Island people.

Terms of reference

1. The Health Advancement Standing Committee will review the current systems within which health promotion occurs, and assess existing health promotion initiatives and evidence-based strategies to develop a detailed plan for the long-term future role of health promotion in Australia. The final report should identify key recommendations for future health promotion activity in all important areas. This report should make particular reference to:

2. Improving the infrastructure in support of health promotion in areas such as: • data collection and surveillance;

• research, including recommendations to facilitate the conversion of knowledge gaps to funded national research projects;

• policy and program planning, including policy and legislative frameworks;

• health promotion financing models, including reviewing funding and purchasing models to develop a funding strategy for health promotion, and addressing the impact of existing health care financing models on health promotion;

• program implementation, program administration and coordination, and organisational structures for health promotion planning and delivery;

• evaluation, including the development of accountability and performance measures (outputs and outcomes), developing proxy criteria for those interventions which may be disadvantaged by the need for ‘evidence-based’ measures (such as community development strategies), recommendations on systems for evaluating and monitoring of progress against program or health status goals, and/or commissioning baseline measurement of some issues over time to assist with the design of further studies;

• intersectoral action, that is, activity within and across all relevant sectors (i.e. not only the health sector) to promote healthy public policy;

• workforce training and education; and • information dissemination and uptake.

3. Considering these structural issues in relation to their appropriate application to the range of health promotion issues, such as health/illness/injury concerns, health status inequalities, population groups, environments, and national health goals, targets and strategies.

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4. Identifying the roles and responsibilities of all relevant agencies with an interest in health promotion (including agencies in the non-health sector). This includes: Commonwealth agencies (with particular reference to the Public Health Division of the Commonwealth Department of Health and Family Services, the Australian Institute of Health and Welfare, the National Health and Medical Research Council, and the Australian Health Ministers’ Advisory Council), State and local interests, non-government organisations, academic institutions, and professional groups.

5. Promoting best practice in health promotion and illness and injury prevention, with due regard to the particular needs of various population groups.

6. Ensuring equality of access to appropriate and affordable health promotion information and services. 7. Maximising all Australians’ opportunity to participate effectively in decisions affecting their health. 8. The final report should:

• detail a range of options for future health promotion action in Australia;

• make specific recommendations in line with the infrastructure issues raised in term of reference 2 above; and

• advise on the interaction of these structural issues with current policy frameworks (e.g. national health goals, targets, and implementation strategies and the National Health Policy), and the broader systems within which health promotion activity occurs.

The report will ensure that health promotion models are fully examined and presented as options for future consideration in the context of a national uniform framework for improving the health of all Australians. As such, it will contribute to the transposition of health promotion for an adjunct to primary and acute care, to a legitimate, effective and equal partner in improving population health status.

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Acknowledgements

Many people have helped develop the ideas for the content of this final Report. The NHMRC Health

Advancement Standing Committee would like to thank all the people who gave their time so willingly to speak with Ms Sandra Angus and the Project Team during the preparation the Discussion Paper and this final Report. Particular thanks is given to the Aboriginal Community and Ton-es Strait Island Community and Aboriginal and Torr-es Strait Islander Advisory Committee, whose voluntary and continuing support and thoughtful advice have proven invaluable to Ms Angus in the course of preparing this paper.

The Project Team would also like to thank Ms Corina Belevi and Ms Anthea Ellison at the National Centre for Health Promotion for their support in our work.

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Abbreviations used in this report

ACCHO AHC AHRC AICHS AIHW AMS AMSANT ATSIC Health personnel NACCHO NAHS NATSIS NHMRC PHERP QAIHF TAHS VACCHO Inc WAACCHO

Aboriginal Community Controlled Health Organisation Aboriginal Health Council, South Australia

Aboriginal Health Resource Cooperative, New South Wales Aboriginal and Islander Community Health Service Australian Institute of Health and Welfare

Aboriginal Medical Service

Aboriginal Medical Services of the Northern Territory Aboriginal and Torres Strait Islander Commission

all Aboriginal and Torres Strait Island health workers, including health promotion officers, specialist health educators, alcohol and drug workers, and sexual health workers

National Aboriginal Community Controlled Health Organisations National Aboriginal Health Strategy

National Aboriginal and Torres Strait Islander Survey National Health and Medical Research Council Public Health Education and Research Program Queensland Aboriginal and Islander Health Forum Tasmanian Aboriginal Health Service

Victorian Aboriginal Community Controlled Organisations, Inc.

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However, what Illich is demanding is reflection by those in power: ‘that the question to be asked first is not what can this advantaged society do to that disadvantaged society?’ ‘Instead, it is: what can it do both to itself and together, to address the imbalances?’

Illich I. Deschooling society. New York: Perennial Library, 1972. Cited in: Hunter E. Aboriginal health and history. Cambridge: Cambridge University Press, 1993.

Indigenous definition of health

Health does not just mean the physical well-being of the individual but refers to the social, emotional, spiritual and cultural well-being of the whole community. This is a whole of

life view and includes the cyclical concept of life-death-life. Health services should strive to achieve the state where every individual can achieve their full potential as human beings and thus bring about the total well-being of their communities. 1

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Executive Summary

The National Health and Medical Research Council’s Health Advancement Standing Committee was commissioned to undertake a comprehensive review and analysis of past and current health promotion

initiatives in Australia. The review was to provide recommendations for a range of actions to improve the range and effectiveness of action to promote the health of Australians. A specific consultation with Aboriginal people and Torres Strait Island people was established as a major component of the review. This Report addresses the issues from the perspective of (and in the words of) Aboriginal people and Torres Strait Island people. Aboriginal people and Torres Strait Island people belong to two different races each of which has a different history, culture and tradition. Each group of people may have totally different issues from the other so it is important not to group the populations together as if they were one. The consultation for this report

endeavoured to include as many Aboriginal people and Torres Strait Island people as possible who work in the area of Aboriginal and Torres Strait Islander health.

In Queensland, in particular, there are groups of South Sea Island people who also have their own history, culture, traditions and specific issues. This group of people has not been consulted specifically for the purpose of this document.

The Report is based upon the results of extensive consultation with and feedback from more than 1 000 Aboriginal and Torres Strait Island health personnel from both the community-controlled and government sectors around the country. Indigenous cultures are so diverse that no single person can be expected to know or include all information about the factors that have an impact on the health status of these groups, or on

improving health outcomes. However, this consultation revealed considerable agreement about the broad issues that need to be addressed. The review also identified actions that are necessary if the health of Aboriginal people and Tort-es Strait Island people is to improve.

The Report highlights the extent to which the history of colonisation has affected and continues to affect the current health status Aboriginal people and Torres Strait Island people in Australia. The health of Indigenous Australians continues to be much poorer than that of their non-Indigenous counterparts, although there have been some improvements. However, compared with improvements in the health of indigenous populations in other nations, there is much yet to be achieved in Australia.

In the views of those people who were consulted in preparing this Report, four principles must underpin the development of the infrastructure support needed for Aboriginal and Torres Strait Islander health advancement in Australia. These are:

1. acknowledgement by non-indigenous Australians that Aboriginal people and Torres Strait Island people have a right to their history, including the effects of colonisation on the health of Aboriginal people and Torres Strait Island people today;

2. the inclusion of Aboriginal and Torres Strait Island communities and individuals in all levels of decision making which affect their lives in general and their health in particular, through a community

development approach;

3. the need for any initiatives to promote the health of Aboriginal people and Torres Strait Island people to be integrated with culturally effective, high quality, accessible primary health care services; and

4. the need for Indigenous and non-Indigenous Australians (and their organisations) to encourage the development of partnerships to improve Aboriginal and Torres Strait Islander health.

The review highlighted the extent to which the improvement of the infrastructure to support Aboriginal and Torres Strait Islander health advancement depends upon the development of more holistic, coherent and cohesive systems to plan and implement both effective primary health care services and health promotion

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programs. It is impossible, in the views of the people consulted during the review, to separate these two issues. Nonetheless, this review has focused primarily on the need for infrastructure to promote health-in addition to the infrastructure for primary health care services.

The review identified many actions already being undertaken by Aboriginal and Torres Strait Island communities to improve their health. The positive outcomes of these and the processes by which they have been developed need to be recognised and encouraged. A companion volume is to be published of case studies that highlight principles of effective health promotion practice in both Aboriginal communities and Torres Strai Island communities.

The review found that the positive actions (some of which are highlighted in the case studies) that have been taken by many Aboriginal and Torres Strait Islander communities would be more sustainable with the support of strong national, State/Territory and local infrastructures. In addition, the consultation highlighted the need for additional infrastructure support to increase the range and effectiveness of action to promote Aboriginal and Torres Strait Islander health. There is much to be gained from the forging of strong partnerships not only between Aboriginal health personnel, among Indigenous health organisations (government and community-controlled) but also between these groups, the mainstream health sector, and other sectors. These partnerships must be between equals and based on recognition of the interdependence of the partners. The guidelines in Appendices 1 and 2 can assist in ensuring the development of such partnerships.

The recommendations outlined in this report identify specific steps that need to be taken to build the capacity of the health sector to support the work of Aboriginal and Torres Strait Island health personnel working in partnerships (with their communities, with their peers, with other sectors and with the mainstream health system) to achieve improved Aboriginal and Torres Strait Islander health.

The terms of reference specified the components of an effective infrastructure. These have been confirmed by this review and the analysis of the case studies. The recommendations include action in the areas of:

• health policy development;

• setting priorities and allocating resources; • program design and organisational support;

• partnerships within the health sector and between the health and other sectors; • monitoring and surveillance;

• research, particularly intervention research, and evaluation; • information dissemination and uptake;

• workforce development; and • access to health care services.

The consultation did confirm the importance of each of the components of infrastructure that had been identified in the terms of reference for the review. However, the Aboriginal people and Torres Strait Island people who were consulted were almost unanimous in their view that any action to promote their health must be based on an understanding of their history since colonisation, and its effects on their health not only in the past, but today.

The issues outlined in this report, therefore, outline, from an Aboriginal and Torres Strait Islander perspective, the determinants of health. The development of the infrastructure support recommended in this report is based on this analysis.

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The issues raised in the review and consultation

Millions of words have been spoken and written about ways to improve Aboriginal health. This review has attempted to acknowledge all that has gone before, particularly the efforts of Aboriginal people and Torres Strait Island people.

One of the first actions that can be taken by the ‘mainstream’ therefore, is to ensure that Aboriginal people and Torres Strait Island people have the opportunity to develop a strong voice with which to speak directly on their own behalf.

The issues identified in this review have all been identified before. This report is another attempt by Aboriginal people and Torres Strait Island people to speak about what they want and need in order to improve their health. That Aboriginal people and Torres Strait Island people have been willing to speak again is a manifestation of the strength of their cultures, of their willingness to seize the opportunity and to take the risk, again, of speaking out. The challenge now is to act upon what has been said, to turn the rhetoric into action and to address the public health problem rather than to continue to describe it.

The issues listed below have been identified through a culturally sensitive process of consultation. The first issue arose from the consultation and review. While the issue itself and the recommendations fall outside the ambit of the terms of reference, there was a very clear mandate from the people and organisations consulted that this issue underpins all the other actions recommended. Each subsequent recommendation has been linked to a specific term of reference.

In all, the Aboriginal people, Torres Strait Island people, the organisations consulted, and the literature that was reviewed in preparing this document pointed to the need for:

Acknowledgement of history

public acknowledgment of the history that determines the health of Aboriginal people and Torres Strait Island people today;

Extended policy framework to provide a mandate for promoting health,

developed with strong Aboriginal and Torres Strait Islander participation

development of an Aboriginal health policy framework that provides a mandate for and direction to

initiatives to promote the health of Aboriginal and Torres Strait Islander populations in addition to policy that focuses on developing and extending culturally effective, accessible health care services;

• strong Aboriginal and Torres Strait Islander voices in the development of Aboriginal and Torres Strait Islander health policy, program delivery and resource allocation;

• a mandate and incentives for health services and individual health personnel to engage in action to

promote health. This will mean developing career structures and pay scales that recognise training, ensure the availability of jobs following training, and ensure support for people who have undertaken training to apply their new learning in their work environments;

• vertical and horizontal equity* in funding for health care services and for additional programs to improve Aboriginal and Torres Strait Islander health and well-being;

• secure, long-term investment in both the infrastructure and major programs needed to promote health and in culturally effective health care services;

Effective health promotion program design and delivery

recognition that, for many communities, the physical/structural environment (remoteness, climate, access to home refrigeration, store food choices, for example) is often not conducive to the adoption of ‘healthy’ lifestyles;

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documentation and dissemination of principles to guide the development of programs to promote Aboriginal and Torres Strait Islander health;

• recognition that the vast diversity of Indigenous communities means that greater attention is necessary to ensure that policies and programs are implemented in ways that are relevant to the different communities and their cultures;

Organisational support for promoting health at national, State, Territory and

local levels

clear lines of responsibility and accountability for funding and programs to promote health and for provision of health care services on the part of different levels of government, and on the part of the different organisations that provide health care and health promotion services to communities;

extended organisational capacity to deliver effective health promotion programs in communities. Health workers, in many cases, are overworked and under-resourced and time spent on acute care often precludes or minimises opportunities to engage in activities to promote health;

Partnerships and intersectoral action

more active partnerships between Aboriginal and Torres Strait Island communities, the Indigenous health sector (both government and community controlled) and between these groups and sectors such as education, housing, justice, employment, and the environment;

• encouragement to form partnerships between Indigenous health personnel and non-Indigenous health workers and organisations;

Monitoring and surveillance

indicators that are relevant to Aboriginal and Torres Strait Islander views of health and its determinants; • monitoring and surveillance systems with particular reference to environmental and social determinants of

Aboriginal and Torres Strait Islander health;

Research and evaluation

an extended research base that helps to identify (from the viewpoint of Aboriginal people and Torres Strait Island people), the causes of health problems, and culturally effective methods of resolving them; • increased funding for Aboriginal and Torres Strait Islander research and for training and support for

Aboriginal and Torres Strait Island public health researchers;

• accurate information about current levels of health promotion program delivery;

• a nationally agreed framework for evaluation of Aboriginal and Torres Strait Islander health promotion;

Access to health care services

access to culturally effective primary, secondary and tertiary health care services.

Workforce development and support

professional training, and ongoing education in health promotion for the Aboriginal and Torres Strait Island health workforce;

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Recommendations for action

The recommendations that follow have been derived from the voices of more than 1 000 Indigenous health personnel and of a range of non-Indigenous health personnel, including the members of the Health Advancement Standing Committee.

The three major findings have been that:

• there is an ongoing need to work in more participatory ways with Aboriginal people and Torres Strait Island people who have the skills, abilities and life experiences to know what is acceptable in their own communities. Aboriginal people and Torres Strait Island people should be recognised as the experts here, but the review has highlighted the need to develop strong partnerships between mainstream health institutions and agencies and Indigenous health institutions, agencies, and communities;

• there is a need to invest in the infrastructure support for Indigenous health advancement if the action that is necessary to promote the health of Aboriginal and Torres Strait Islander populations is to be sustained; and

• all efforts to promote the health of Indigenous Australians must begin with an understanding and acknowledgement of the effects of their history on their health today.

With the exception of the first three recommendations each has been linked with the relevant term of reference.

1.

Public acknowledgment of the determinants of Aboriginal health

The Aboriginal and Torres Strait Islander health personnel consulted in preparing this report made it very clear that public acknowledgement of the effects of their history on the health of Indigenous Australians is a prerequisite for improving their health. They recognised that acknowledgement, on its own, cannot overcome the effects of history. Nonetheless, the people consulted during this review emphasised again and again that public acknowledgement is the first step toward an improvement in their health and well-being.

It is recommended that

the Federal Minister for Health and the National Aboriginal and Torres Strait Islander Health Council commission the Council to develop a public statement acknowledging the significance of the history of colonisation for the health of contemporary Aboriginal Australians;

• all documents published by the Department of Health and Family Services with regard to Aboriginal and Torres Strait Island people’s health include a preface that sets out the effects that colonisation has had on the health of Aboriginal and Torres Strait Islander populations; and

all documents published by State and Territory health departments with regard to Aboriginal and Torres Strait Island people’s health include a preface that sets out the effects that colonisation has had on the health of Aboriginal and Torres Strait Islander populations.

2.

Ensure strong Aboriginal and Torres Strait Island voices are engaged

in developing health policy, setting priorities, and allocating resources

The review highlighted the need for the inclusion of Aboriginal and Tort-es Strait Island voices in the development and implementation of Australia’s actions to identify and solve public health problems. The Commonwealth and State/Territory governments are currently engaged in the development of a National Public Health Partnership to:

involve both levels of government (Commonwealth and State) in jointly setting objectives, priorities and performance standards and funding the system; with the Commonwealth

taking a leadership role in relation to public health standards and health research, and the States primarily responsible for managing and coordinating the provision of services and

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This proposal was agreed to by the Council of Australian Government in June 1996. The Partnership represents an important step toward a more systematic, cohesive national approach to identifying and solving public health problems.

The objectives, roles and structures of the National Public Health Partnership have not been finalised, but it will have major significance in determining future priorities for action, resource allocation, and policy direction in relation to public health in Australia. It is processes such as this in which a strong Aboriginal voice is required. The National Aboriginal and Torres Strait Islander Health Council is a representative body that could collaborate with the Partnership to ensure that Aboriginal and Torres Strait Islander perspectives and needs are considered directly in the formation of the Partnership and its work program.

In 1995 the Australian Health Ministers in each state signed agreements with National Aboriginal Community Controlled Health Organisations and the Aboriginal and Torres Strait Islander Commission aimed at improving the health of Aboriginal people and Torres Strait Island people. These Framework Agreements aim to improve health outcomes through the better allocation of increased resources, improved access to health services, and better cooperation with all levels of government. The Agreements set out the roles, responsibilities and lines of accountability of each of the major organisations involved in planning, delivering and evaluating programs and services to diagnose, treat, and prevent illness in Aboriginal and Torres Strait Islander populations and to promote their health.4

It is planned that these Agreements will result in the establishment of a State/Territory health forum in each jurisdiction. The forum will include representation from Commonwealth and State/Territory health departments,

key State/Territory health organisations, NACCHO (through its State/Territory affiliates) and ATSIC and will focus particularly on the development of regional planning processes, including the identification of gaps and opportunities in service provision, and priorities to improve health services and environmental health in the region. The forum will also provide a mechanism for consultation and will undertake wide canvassing of key stakeholder groups.5

For Aboriginal people and Torres Strait Island people living and working at community level, there are extensive demands to be involved in a range of planning and decision-making forums, and the results from the effort are not obvious to them. Clarity is needed so that organisations and people know what decisions they are being called upon to make, so that when decisions about direction, programs, and funding are made they can be acted upon, and so that people at each level are clear about what they are accountable for achieving.

The Agreements, the National Aboriginal and Ton-es Strait Islander Health Council and the National Public Health Partnership offer mechanisms to increase coordination and cooperation and to achieve greater effect.

It is recommended that:

The National Public Health Partnership collaborate with the National Aboriginal and Torres Strait Islander Health Council to ensure the involvement of Aboriginal people and Torres Strait Island people in the development of:

- the National Public Health Partnership Work Program; - the proposed Public Health Outcome Funding Agreement; and

- the delineation of national, Commonwealth and State/Territory roles and responsibilities in the area of public health including health promotion.

TOR: 2.3,7

3.

Invest in health promotion program delivery infrastructure

Most of the current infrastructure for Aboriginal and Torres Strait Islander health focuses on the provision of health care services, largely at the primary health care level. Both government and community-controlled organisations in all States and Territories have begun to develop a more definitive approach to promoting health. However the review found that most health personnel were carrying out activities to promote health in

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addition to their clinical work, often with very limited time and almost no additional resources.6

The review has confirmed that the capacity to deliver high quality, effective action to promote health depends upon there being a well developed infrastructure to direct and support the action.7

The remaining recommendations highlight components of the infrastructure to promote Aboriginal and Torres Strait Islander health and propose steps to be taken to develop these. Without such an infrastructure it will be almost impossible to deliver the extensive, sustained, high quality action by all parts of the health sector (and other sectors) that is necessary to promote Aboriginal and Torres Strait Islander health.

It is recommended that:

The National Aboriginal and Torres Strait Islander Health Council, in partnership with the National Public Health Partnership:

- require all States and Territories to develop and implement an Aboriginal and Torres Strait Islander health policy (in collaboration with State/Territory and community controlled Aboriginal and Torres Strait Island communities and organisations); (TOR 2.3)

- develop minimum standards that specify the infrastructure necessary at the Commonwealth level and in each State and Territory to support the development and implementation of effective action to promote the health of Aboriginal people and Torres Strait Island people; (TOR 2.5)

• the Commonwealth Department of Health and Family Services continue to provide resources for national secretariat support for peak organisations including NACCHO to enable them to contribute a national, community-controlled organisational perspective to the Aboriginal and Torres Strait Islander Health Council and to other bodies and sectors that develop and contribute to national health policy; (TOR 7) • at regional and area levels, agreements be developed between the State/Territory NACCHO affiliate

organisation and State/Territory health authorities defining roles and responsibilities (including joint responsibility) and lines of accountability for promoting health. The agreements should specify the development of a defined public health/health promotion program focused on improving Aboriginal and Torres Strait Islander health that is an integral, but specifically funded component of the primary health care program. (TOR 2.4, 4)

Such agreements would recognise the need for active community involvement in the processes of setting priorities, planning and implementing interventions, and in evaluating the process and impact of

interventions. The agreements should help facilitate the development of partnerships among major service provider organisations (including mainstream health services), thereby ensuring that the best use is made of resources, including the expertise of the health personnel in different organisations.

4.

Strengthen the capacity of primary health care services to

promote health

Primary health care is widely agreed to be the most appropriate model of service provision for providing health services (diagnosis, treatment) for Aboriginal communities and for providing the base from which to develop public health/health promotion programs and services.8 9 10

The National Aboriginal Health Strategy advocates a primary health care philosophy as the appropriate approach to Aboriginal and Torres Strait Islander health programs, and recognises Aboriginal and Torres Strait Islander health workers as the link between communities and the health system, as central to continuity of care, and to community development and education towards self management.”

The Queensland Aboriginal and Torres Strait Islander Health Policy, for example, identified seven key areas for future action, of which the first three are:

• community control of primary health care services; • participation; and

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culturally appropriate service provision.

These fit with the primary health care model used by the Central Australian Aboriginal Congress12 and recommended by Bartlett and Legge.13 The model integrates several important prerequisites for improving Aboriginal health:

• community control of planning, management and delivery of services (whether the service is developed under the auspice of NACCHO or State/Territory government);

• the provision of preventive and acute health care services;

• the use of community development to underpin the development of all services and programs, including those to promote health; and

• the need for programs that are specifically designed to improve environmental health.

Community development, in this context, is a process to ensure that Aboriginal people are in control of decisions that are made about actions taken to improve their health.

While the primary health care infrastructure does offer a significant base from which to promote health, many of the health personnel consulted during this review had experienced difficulties in carrying out high quality, sustained health promotion. The demands of acute care, the ways in which their work was organised and rewarded, and the lack of resources for training were barriers to the development of more effective practice. To enable them to undertake more effective health promotion, the health personnel agreed that there is a need for a mandate for them to engage in activities to promote health that are not connected, directly, with the provision of health care services. This is in addition to the training and resources that they also require. While a mandate or policy can seem to be a subtle component of infrastructure at some levels, in practice, without such a mandate the urgency of the needs of people requiring treatment often means that the work of promoting health must be set aside.

It is recommended that:

. the Commonwealth, States and Territories, through the Framework Agreements reached to improve the

coordination of delivery of health services to Aboriginal people and Torres Strait Island people, agree on the following as a minimum infrastructure for primary health care services to support action to promote health:

- a community controlled management group that outlines needs, plans services and programs, and allocates funds;

-primary clinical care services that meet a set of nationally agreed standards;

access to secondary and tertiary clinical and support services (such as hospitals, medical and public health specialists);

- public health and health promotion services to address physical and social environmental health issues (in collaboration with other sectors), and to work with the community to improve health literacy and skills.

This infrastructure will need to be supported by training for community members to ensure that they are equal partners in planning services; by data that is presented in ways that communities are able to use effectively; and by funding that recognises that community development is a critical feature of effective action to solve public health problems.

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5.

Build effective partnerships within the health sector, with communities,

and with other sectors

Intersectoral alliances

The health of Aboriginal people and Torres Strait Island people can only improve when all the sectors and settings that have an impact on their lives are engaged in working with Aboriginal and Torres Strait Island communities to bring about change. It will be necessary for Departments of Education, Employment, Housing, and Justice, for example, to work with Aboriginal and Torres Strait Island health personnel and the health sector to ensure that the decisions made by these sectors contribute to the health of Aboriginal people and Torres Strait Island people.

The process

Empathy and understanding are essential to create effective alliances for health.14 This is particularly true for Aboriginal people and Torres Strait Island people, who must be engaged in setting priorities, as well as in planning and delivering programs and services.

Most people consulted in the course of this review confirmed the need to build alliances as an essential ‘next’ step toward developing more effective services and programs to promote the health of Aboriginal people. In the view of the people consulted, alliances are needed between:

• the Commonwealth Department of Health and Family Services, the State/Territory health authorities, and the National Aboriginal Community-Controlled Organisations;

• community-controlled and State/Territory Aboriginal health services;

• health service providers (government and/or community-controlled) and their communities;

• health service providers (Indigenous and non-Indigenous), communities, and other sectors (at the local level);

• State/Territory health authorities, NACCHO, and other sectors (at the State/Territory and national levels). The review also highlighted the need for a focus on action to promote health in addition to the need to improve people’s access to high quality health care services. While the need for culturally effective health care services is an essential prerequisite for improving the health of Aboriginal people and Torres Strait Island people, health care services are not sufficient, on their own.

The holistic approach to their health taken by Aboriginal people and Torres Strait Island people, and the complexity of the determinants of health mean that a ‘whole of government’ approach will be required to improve the health of Indigenous Australians. That it is possible to achieve effective action through collaboration has been demonstrated in several important projects undertaken by and with Aboriginal and Torres Strait Island communities.15

Working with other sectors to promote health requires sensitive action by the health sector.16 However, above all, Aboriginal people and Torres Strait Island people themselves must be engaged as equal partners in making all decisions about actions that affect their health and well-being. The proposed health forums that are to be established in each of the States and Territories as part of the recent Agreements reached between the Commonwealth and States/Territories, NACCHO (through the State/Territory affiliates) and ATSIC offer a mechanism to ensure strong Aboriginal and Torres Strait Island voices in decisions affecting their health made by the health sector and/or other sectors.

It is recommended that:

the State/Territory health forums:

- define priorities and assign responsibilities for working with other sectors at State/Territory level to develop policies and programs designed to improve Aboriginal health. This would include working with the Departments of Housing, the Environment, Education for example;

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- develop mechanisms by which communities will participate in decisions made by other sectors that affect their health;

• the National Public Health Partnership Work Program establish an ongoing relationship with the National Aboriginal and Torres Strait Islander Health Council to identify opportunities to work jointly to develop and implement intersectoral action with particular reference to the needs of Aboriginal and Torres Strait Island communities.

TOR 2.7

6.

Monitoring and surveillance

The Australian Institute of Health and Welfare has identified three main areas in which further work is needed to improve national information on the health of Aboriginal people and Torres Strait Island people. The first is to improve the identification of Indigenous people in all health and vital statistics collections.

The second is to improve the capacity of national household surveys to yield Aboriginal and Tort-es Strait Islander data, and to ensure that the questions included in the surveys will provide information that is of value to Indigenous people themselves.

Finally, the need is to continue to produce information that allows the links among employment status, land tenure, housing and health to be explored, as was achieved in the National Aboriginal and Torres Strait Islander Health Survey in 1994.17

Above all, the health personnel consulted pointed to the need for Aboriginal people and Torres Strait Islander people to be partners in the development of monitoring and surveillance systems pertinent to their health.

It is recommended that:

. designated funding be provided to enable the Australian Bureau of Statistics to continue to conduct regular national health and risk factor surveys for Aboriginal and Torres Strait Island people; . the Australian Institute of Health and Welfare be provided with additional funding to work with

Aboriginal and Torres Strait Islander communities to develop a plan to improve all aspects of information about their health and its determinants and about access to health services.

TOR 2.1

7.

Research and evaluation

The consultation revealed widespread concern about the lack of appropriate research available to assist Aboriginal and Tort-es Strait Island communities to make decisions about priorities for and effective action to promote health. Both the focus of much research in their communities and the research process have been questioned by Aboriginal people and Torres Strait Island people. In this, as in so many other areas of

infrastructure support, it will be necessary to act to develop the capacity of Aboriginal people and Tort-es Strait Island people to define their research questions and to undertake the research themselves.

In addition to the need for more relevant research, there is a continuing need for evaluation of action to promote Aboriginal and Torres Strait Islander health. The review highlighted the lack of knowledge about programs that have been developed and implemented already, and about the amount and type of resources that are allocated to promoting health. The review also highlighted the need for culturally relevant program evaluation models18 that can be used by health personnel with their communities to monitor program quality, and to identify outcomes.19 A system to monitor the inputs to programs to promote health and the volume and range of activity across the country will need to be agreed upon nationally (through the National Aboriginal and Torres Strait Islander Health Council), and be sufficiently flexible to account for differences in culture and program delivery.

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It is recommended that:

. the NHMRC identify specific funding for research to support action to promote Aboriginal and Torres

Strait Islander health amongst its priorities during its next triennium;

. the NHMRC establish a ‘research advisory group’ to assist Aboriginal and Torres Strait Islander communities to conduct research and evaluation of actions to promote health;

. the NHMRC allocate specific funding for research proposals from Aboriginal and Torres Strait Island communities;

. the NHMRC ensure that its guidelines do not exclude Aboriginal people and Torres Strait Island people from undertaking research;

. the NHMRC regularly review its guidelines for research in Aboriginal and Torres Strait Islander communities, promote good practice, and ensure that its standards are met in all relevant proposals for funding;

. the NHMRC include amongst its criteria for proposals for research among Aboriginal people and Ton-es Strait Island people, evidence of a partnership between the researchers and the community in which the research is to occur;

. the NHMRC seek to include Aboriginal and Torres Strait Islander representation on each of its Committees or Working Groups during its next triennium;

. the National Aboriginal and Torres Strait Islander Health Council commission a project to develop a system to identify activities being undertaken to promote Aboriginal and Torres Strait Islander health and the resources allocated to this; and

. the National Aboriginal and Tones Strait Islander Health Promotion Network, in collaboration with the Council of Remote Area Nurses of Australia Inc., and the Aboriginal and Islander Health Worker Journal

endorse and disseminate guidelines on evaluating Indigenous health promotion projects. TOR 2.2, 2.6

6.

Improving the cultural sensitivity and effectiveness of mainstream

health services

The consultation found that many Aboriginal people and Torres Strait Island people must use mainstream health services that are culturally insensitive, ineffective, or inappropriate to their needs. Their experience found that there is continuing and widespread lack of understanding of the needs of Aboriginal people and Torres Strait Island people among non-Aboriginal health professionals-particularly understanding of the way in which historical events underpin much of the ill health experienced by Aboriginal people and Torres Strait island people. The review pointed to the need for continuing effort to improve the cultural effectiveness of the services offered by all mainstream health services to their Aboriginal clients and patients.

It is recommended that:

. all professional preparation courses for health professionals include assessable instruction on the history and culture of Aboriginal people and Torres Strait Island people and on their needs from the health care system;

. all institutions that are involved in training health professionals be audited regularly by the Department of Employment, Education and Training to assess the extent to which they have succeeded in training Aboriginal and Torres Strait Islander health professionals;

* The Nganampa Health Service, in collaboration with the Australian Community Health Association’s CHASP program and the Menzies School of Health Research, has done considerable work in developing standards for Aboriginal Health

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. the Australian Community Health Association and the Australian Council on Healthcare Standards be funded to develop appropriate standards for the delivery of services (including health promotion) to Aboriginal and Torres Strait Island clients and patients of mainstream services;

. the National Aboriginal and Torres Strait Islander Health Council commission a project to develop standards for the health care and health promotion services delivered by community controlled and government Aboriginal health services;*

. the National Aboriginal and Torres Strait Islander Health Council commission the development of training programs to support Indigenous health professionals to take up management roles in mainstream as well as in Indigenous-specific services;

. that State/Territory health authorities provide training and support for mainstream health professionals to work more closely with their local Aboriginal and Torres Strait Island communities; and

. the NHMRC, in collaboration with the National Aboriginal and Torres Strait Islander Health Council, develop and disseminate guidelines for survey research in Indigenous communities, for collaboration with Aboriginal people and Torres Strait Island people, and on protocols for contact with communities.

TOR 2.1, 2.2, 2.8

9.

Build on and disseminate principles for effective health promotion

program development and delivery

This review identified many examples of effective programs to promote the health of Aboriginal people and Torres Strait Island people. There is a newly emerging set of principles20 to guide governments, communities and individuals wanting to promote the health of Aboriginal people effectively. The case studies prepared in conjunction with this project highlight principles of good practice and the infrastructure support necessary to ensure effective, sustainable health promotion in Aboriginal and Torres Strait Island communities.

It is recommended that:

. the National Aboriginal and Torres Strait Islander Health Promotion Network be supported to facilitate

the exchange of information about effective Aboriginal and Torres Strait Islander health promotion programs, to contribute to the development of professional practice, and to provide professional support to Aboriginal and Torres Strait Island health personnel working to promote health;

. the Aboriginal and Islander Health Worker Journal be provided with additional funding to provide a special section in each issue highlighting an Aboriginal or Islander health promotion program; and . the National Aboriginal and Torres Strait Islander Health Council commission the development of a ‘web

site’ to enable Aboriginal and Torres Strait Island health personnel access to national and international information on Indigenous health promotion.

TOR 2.9

10.

Workforce development

While Indigenous health personnel are increasingly expected to deal with complex and difficult problems, the rate at which they are acquiring professional skills as well as their levels of remuneration do not appear to be keeping pace with the rising expectation.21It is important not to imply that Aboriginal and Torres Strait Islander health can be improved simply by ensuring that all members of Aboriginal and Torres Strait Island populations have access to education or by improving the training of Aboriginal and Torres Strait Island health personnel. However, education and training are necessary components of the infrastructure to support action to promote health.

Workforce development is required at several levels to ensure that Aboriginal people and Torres Strait Island people are employed throughout the health workforce.

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There is a need to ensure that all Aboriginal and Torres Strait Island children, adolescents, and adults have access to schooling and support so that they achieve levels of literacy and skills that are the equivalent of their non-Indigenous counterparts.

Aboriginal children and Torres Strait Island children, adolescents and adults should be encouraged and supported to continue their schooling to levels sufficient to enable them to undertake training and professional education generally in areas such as nursing, medicine, teaching, and particularly in public health and health promotion.

Tertiary institutions that offer such courses need to ensure that they are appropriate to the needs of Aboriginal and Torres Strait Island students, that they are accessible and flexible, and that support networks are in place. The institutions also need to ensure that Aboriginal people and Torres Strait Island people are encouraged to enrol and that they are supported throughout their course of study.

Most Aboriginal and Torres Strait Islander health personnel are eager for new knowledge and were very interested in developing their knowledge and skills in health promotion and in undertaking training. The training required must be based upon respect for the knowledge and skills brought by Aboriginal people and Torres Strait Island people based on their own lives and that of their communities. As Bartlett and Legge point out, ‘unless the drive and agency of Aboriginal people themselves is recognised and placed at the centre of policy making, program design and service delivery (and training) the technical power of experts will remain relatively ineffectual.’22

There is, currently, no formally constituted professional body for Aboriginal and Torres Strait Island health personnel (at all), and none for people with specific roles and interests in health promotion. The National Aboriginal and Torres Strait Islander Health Promotion Network is an informal body made up of Aboriginal and Torres Strait Island health personnel who work in or have an interest in health promotion. The level of interest in the Network (which has met only twice) has demonstrated the need for a group that can offer professional support for people wanting to focus on health promotion in particular, opportunities to network and share experiences, and to contribute to the development of appropriate training. The National Aboriginal and Torres Strait Islander Health Council has established a Sub-committee on Workforce Issues and this promises to be an important body to coordinate national action to improve the training for and working conditions of Aboriginal health personnel.23

The Public Health Association’s Special Interest Group in Aboriginal Health also includes Aboriginal people with public health and/or health promotion interests. The Australian Association of Health Promotion Professionals, too, is an organisation that has the potential to provide local or regional support to Aboriginal health promotion workers in some, but not all, States/Territories.

Not only training is required. Training must be linked with access to jobs, to career structures and pay scales that recognise and reward training. The NHMRC’s Aboriginal and Torres Strait Islander Health Standing Committee has developed a national training and employment strategy for Aboriginal and Torres Strait Islander health workers and professionals working in Aboriginal and Torres Strait Islander health.24

A National Aboriginal and Torres Strait Islander Health Worker Competency Development Project has drafted national competency standards for Aboriginal and Torres Strait Island Health workers. However, among the six streams into which the 79 units of competency are grouped, there is no ‘health promotion’ stream. The focus of the other six is on working with individuals who require health care services. This is appropriate and necessary, but it does not appear to differentiate between the provision of these services and the different knowledge and skills that are required to promote health effectively.

It is recommended that:

. the National Aboriginal and Torres Strait Islander Health Council explore the opportunity to work with

State/Territory Departments of School Education to ensure Aboriginal and Torres Strait Island children and adolescents have access to culturally effective schooling;

. the National Aboriginal and Torres Strait Islander Health Council, through its Sub-committee on

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and Training to review and develop programs to encourage and support Aboriginal people and Torres Strait Island people to undertake tertiary education and training in a wide range of disciplines, including health-related disciplines;*

. the Commonwealth Department of Health and Family Services, through the Public Health Education and Research Program (PHERP), ensure that there is at least one, nationally accredited course in Indigenous health promotion available in each State/Territory;

. the NHMRC continue its support for and promote a program (including scholarships and traineeships) to train and support Aboriginal and Torres Strait Islander researchers;

. that the courses in Indigenous Health Promotion be reviewed by the National Aboriginal and Torres Strait Islander Health Promotion Network, and the Public Health Association’s Aboriginal Health Special Interest Group for relevance and technical accuracy;

. the National Aboriginal and Torres Strait Islander Health Worker Competency Standards be extended to include more comprehensive ‘units of competency’ in health promotion;

. the Commonwealth Department of Health and Family Services, through the Community Sector Support Scheme (formerly the Community Organisations Support Program) provide funding to employ a Coordinator to oversee the implementation of the recommendations in this report. The role would have a particular focus on workforce development and the person would:

- contribute to the development of professional preparation and continuing education in promoting health for Aboriginal and Torres Strait Island health personnel;

- ensure professional support for the Aboriginal and Torres Strait Islander health promotion workforce including the development of the National Aboriginal and Torres Strait Islander Health Promotion Network,

- advocate for actions to support Aboriginal and Torres Strait Islander health advancement. TOR 2.8

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Part 1:

The consultation with Aboriginal and

Torres Strait Island health personnel,

organisations and communities

The National Health and Medical Research Council’s Health Advancement Standing Committee was commissioned to undertake a comprehensive review and analysis of past and current health promotion initiatives in Australia. The review was intended to inform the preparation of a report by the Committee detailing a range of actions to strengthen action to promote the health of the population. A specific consultation with Aboriginal people and Torres Strait Island health personnel from government and community controlled organisations was established as a major component of the review. The consultation with Aboriginal health personnel, organisations and communities began in February 1996 with the appointment of an Aboriginal Project Officer.

A Discussion Paper based on the first round of consultation was distributed for comment in August 1996. (The process and feedback from this consultation can be found in Appendix one and two). This Final Report has been amended to incorporate the feedback received on the Discussion Paper. The Report addresses the issues that need to be addressed from the perspective of (and in the words of) Aboriginal people and Torres Strait Island people.

The consultation process

At the second annual meeting of the Aboriginal and Torres Strait Islander Health Promotion Network in February 1996, a national Aboriginal and Torres Strait Islander Advisory Committee was formed to advise and support the Project Officer. Members of the Network outlined a range of issues that they considered necessary to address in order to improve the quality and effectiveness of action to promote the health of Indigenous Australians. Using formal and informal networks and advice on key stakeholders from the Advisory Committee, the Project Officer wrote to more than 300 Aboriginal and Torres Strait Islander community-controlled organisations, government departments and non-government organisations to invite them to participate in the consultation. Much of this correspondence was followed up with telephone calls.

Most people were more than willing to be involved and the number of people and organisations consulted then grew through other formal and informal networks. By the time of publication of this Report the consultations had encompassed all States and Territories, including the Torres Strait. More than 1 000 people (predominantly Indigenous) from government and community-controlled organisations had identified issues and

recommendations that were included in the Discussion Paper. Following the second round of consultation, further comments were received both verbally and in writing for inclusion in the Final Report.

A series of case studies of examples of effective Aboriginal and Torres Strait Islander health promotion will be published in a companion document. Copies of both reports will be distributed to every person and organisation who has contributed to the consultation. It has also been possible to compile a database which lists Aboriginal and Torres Strait Island health personnel by their title, area of skill, specific program interest, educational achievements, and contact details.

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In August 1996 a Discussion Paper was released for public comment. It was distributed to: 1. each person who had contributed to the consultation to date;

2. 3.

community leaders;

Office of Aboriginal and Torres Strait Islander Health Service, Commonwealth Department of Health and Family Services;

4. the Directors of Aboriginal Health in each State and Territory; 5. the National Chairman of NACCHO;

6. the State and Territory representatives of NACCHO;

7. the Chairperson of the Aboriginal & Torres Strait Islander Health Standing Committee of the NHMRC; 8. the Health Advancement Standing Committee of the NHMRC;

9. the Office of the NHMRC;

10. the administrators of all Aboriginal and Islander community-controlled health services; 11. Chairs of the State Tripartite Forums;

12. Aboriginal and Torres Strait Islander Commission;

13. Chair of the Queensland Aboriginal and Islander Health Forum; 14. State/Territory Directors of Public Health;

15. State/Territory Directors of Health Promotion; and 16. other interested parties on request.

The names of the individual people and organisations that have contributed to this review are listed in Appendix three.

Figure

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References

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